Introduction to Home Health Care: Physician's Role and Benefits

1. An Introduction to Home Health Care in the United States: Role of the Physician and Benefits of Home Health Care Tracy Gutman, MD Geriatrics Fellow University of Kansas

2. OBJECTIVES:By the end of this module, the learner will do the following: Identify the two major roles that physicians play in home health care. List the four general types of physician home visits. List the major indications for physician home visits . Describe some of the components of a home safety assessment. Explain how multidisciplinary long term provision of home health care services benefits patients. Identify some of the positive outcomes of home health care, including benefits to patients and cost savings.

3. Pretest 1. True or False: Medicare does not require a licensed physician to order and oversee home health care services.

4. 2. Multiple choice:Physicians receive reimbursement from Medicare for care plan oversight for all of the following except: Communicating with nurses or therapists Talking with patients and families over the phone Reviewing labs not associated with physician visits to patients Certifying and recertifying the care plan Pretest

5. 3. Multiple choice:Indications for physician home visits include all of the following except: Evaluation of suspected elder abuse or neglect Patient failure to thrive Caregiver’s convenience Limited mobility or difficulty transporting the patient to doctor’s appointments Pretest

6. Pretest 4. True or False: The Medicare home health care requirements of homebound status and skilled need apply to occasional physician home visits.

7. 5. Multiple choice:Which of the following best describes typical homebound patients? Homebound patients tend to be frail with significant functional impairment and multiple chronic diseases Homebound patients are usually independent in their activities of daily living Homebound patients have much better functioning than nursing home patients The population of homebound patients is decreasing Pretest

8. 6. Multiple choice:Which one of the following is not true regarding the benefits of home health care? Improves patient and caregiver satisfaction Improves medication administration Improves management of chronic diseases None of the above Pretest

9. Pretest 7. True or False: Home health care is cost effect in providing post hospital transitional care.

10. Pretest Answers false b. c. false a. d. true

11. Section One:The Role of the Physician in Home Health Care Medicare requires a licensed physician to order and oversee home health care services.3 Physicians refer homebound patients with skilled care needs to home health care agencies.1 Physicians make home visits.

12. Oversight of Care Plan1,2 The physician ordering home health care services receives reimbursement for certification and oversight of the care plan as well as for coordinating care. Medicare Part B pays the physician, but patients pay 20% of the cost. To receive reimbursement, the physician must spend a minimum of 30 minutes per month on home health care related activities, But the physician does not receive payment for time spent speaking with patients or family members.

13. Physician Home Visits10,11,12 Evaluate the patient in the home environment. Identify new problems, assess functioning in the home, and provide comprehensive assessment. Provide new interventions, assess medication compliance, and recommend environmental modifications. Examine patients, conduct diagnostic tests, prescribe medications, and educate patients, families, and caregivers about management of chronic diseases. Perform some procedures in the home as well as refer patients for other testing and services.

14. Specific Types of Home Visits11 Acute and chronic illness Hospice/end of life care Comprehensive home assessment Hospitalization follow-up

15. Indications for Home Visits11 Physical impairment and limited mobility or limited transportation to doctor appointments Assessment of caregiver burden Suspected elder abuse or neglect Failure to thrive Falls Psychiatric illness and behavior problems Evaluation of need for nursing home placement

16. Home Safety Assessments11 Physicians can conduct safety assessments, although more typically occupational therapists perform them. Look at housekeeping, cleanliness, crowding, and emergency exits. Assess patient’s nutritional situation by examining refrigerators and cupboards and discussing meals, smoking, and alcohol. Determine a patient’s need for other home health care services.

17. Elements of a Home Safety Assessment11 Check the appliances in the kitchen, assess cooking ability Assess the bathroom for hand-holds, raised toilet seats, nonslip showers, nonslip floors, Assess stairs for handrails, secure carpet, and proper lighting Assess maintenance of utilities, including heating and air conditioning Check for smoke detectors, fire extinguishers, appropriate lighting and night lights Check for safe hallways and walkways, free of loose carpet and throw rugs

18. Reimbursement for Physician Home Visits The Medicare home health care requirements of homebound status and skilled need do not apply to occasional physician home visits.2 Reimbursement rates have varied over time. In 1998, Medicare instituted new billing codes that increased reimbursement for home visits by 50%.7 However, reimbursement decreased by almost 20% between 2005 and 2008.7 Reimbursement depends in part on physician billing, which focuses on documentation, including evaluation of a patient’s functioning, caregiver issues, and discussion of the plan of care.10

19. Physicians and Home Technology7 Use of mobile medical technology, such as lab testing and diagnostics in the home Participation in telehealth: telecommunication with patients using interactive video, telephone, and/or Internet to aid in diagnosis and treatment as well as health care maintenance and disease prevention

20. Few Physicians Actually Provide Home Visits Patients receiving home health care services typically do not receive physician home visits as part of their care. Overall, primary care physicians in the United States do not incorporate home visits into their practices. Physicians in England make 10 times the number of home visits per 1,000 patients per year compared with U.S. physicians7 and make 100 times as many home visits to patients older than 85 years.7

21. Section Two:Benefits of Home Health Care Home health care has the potential to benefit a large number of chronically ill adults, especially older adults, living in the community. Approximately 1 million individuals aged 65 and older are permanently homebound.13,8 An estimated 5.8 million community-dwelling older adults meet the Medicare definition of homebound either permanently or temporarily due to illness or injury.13,8

22. Needs of Homebound Patients Homebound patients tend to be frail, with significant functional impairment and many chronic diseases.13 More than 5.4 million community dwelling adults have limitations in at least 1 activity of daily living; about 3 times that number have limitations in instrumental activities of daily living.5 Many homebound community dwelling older adults have enough functional impairment to be eligible for a nursing home level of care.13 By 2020, 2 million older adults will be chronically homebound due to functional impairment.13

23. Benefits of Home Health Care1,8 Improved health outcomes, functionality, and quality of care patient and caregiver satisfaction and improved medication administration management of chronic care conditions transitions to home from hospitals, rehabilitation facilities, and nursing homes Decreased hospitalization rates ER visits functional decline Reduced social isolation institutionalization and nursing home use

24. Benefits of Multidisciplinary Continuous Long Term Home Health Care Comprehensive home health care services with medical, psychosocial, functional, and environmental components and continuous long term follow up visits have been shown to improve functional stability and decrease nursing home admissions.

25. Benefits of Multidisciplinary Continuous Long Term Home Health Care (cont.) Studies of home health care programs that provided comprehensive assessment and follow up visits with a minimum of 9 or more home visits demonstrated a 24% reduction in functional decline; a 34% reduction in nursing home admissions; decreased rates of hospitalization, number of ER visits, and mortality; and increased satisfaction with care.8,7

26. Home Health Care Cost Savings1 Studies of older adults with specific chronic diseases have shown that home health care can substantially decrease costs. In patients with heart failure, costs declined by 50%. Home health care has also been cost effective in patients who need short term post hospital post acute transitional care where it has successfully prevented readmissions and shortened hospital stays.

27. Benefits of Home Occupational Therapy and Physical Therapy4 Improves activities of daily living. Decreases falls. Increases social participation. Improves subjective quality of life. Reduces caregiver burden. Improves health status.

28. Benefits of Home Health Nursing4 Improves activities of daily living. Improves health status. Decreases mortality rates. Decreases use of hospitals. Delays nursing home admission.

29. Home Health Care Mental Health Benefits Social assistance through home social workers4 reduces symptoms of depression and anxiety and increases social integration. Intensive psychiatric home care by home care teams is cost-effective and successful.1

30. Post-test 1. True or False: Physicians do not usually actively participate in the development and implementation of the home health care plan other than certifying and recertifying it.

31. Post-test Multiple choice: Physician home visits typically include all of the following except: • Assessment of caregiver burden • Medication review • Comprehensive and complete home safety assessments • Direct observation of activities of daily living

32. Post-test 3. True or False: Overall, primary care physicians in the United States do not incorporate home visits into their practices.

33. Post-test 4. Multiple choice: What is the minimum number of home visits that has been shown to provide the most benefit in home health care programs that provide comprehensive, continuous care? • 3 • 5 • 7 • 9

34. Post-test 5. True or False: Home health care is cost effective for both long term care and short term post acute care.

35. Post-test 6. Multiple choice: Benefits of home physical and occupational therapy include all of the following except: • Decreased use of assistive devices • Improved subjective quality of life • Reduced caregiver burden • Decreased falls

36. Post-test 7. True or False: Telehealth is telecommunication with patients using interactive video, telephone, and/or Internet to aid in diagnosis and treatment.

37. Post-test Answers true c. true d. true a. true